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Significant reform of the health care system sufficient to achieve universal coverage, a value-driven system and administrative simplification faces enormous barriers at the level of our societal ecosystem – barriers as large as any that can be faced in public policy. These barriers exist within the health system itself as a complex adaptive system, and are structured by our economic, legal, cultural and political systems. Because there are so many barriers, significant reform is a relatively rare occurrence. Yet it does happen and there are some important examples of major health care reforms. There are a number of lessons to be learned from the successful enactment of the Medicare and Medicaid programs that appear relevant to current and future reform efforts. First, a necessary condition for achieving significant reform is the existence of large and sufficiently enduring social forces sufficient to disrupt legislative and policy stasis and drive the necessary political solutions. Second, public sentiment and electoral "mandates" might be necessary to significant reform, but they are not sufficient. Third, assuming the theoretical capacity to manage the constellation of systemic, economic, legal, cultural and legislative barriers, there remains a political "tipping point" that must be crossed and translated into a Congressional super-majority in order to enact significant nationwide reform. [ABSTRACT FROM AUTHOR]

The article presents instructions for authors who wish to contribute research papers in the forthcoming issues of the journal "Archives of Otolaryngology--Head & Neck Surgery." If authorship is attributed to a group, all members of the group must meet the full criteria and requirements for authorship described in these Instructions. A group must designate at least I or more individuals as authors or members of a writing group who meet full authorship criteria and requirements and who will take responsibility for the group, in which case the other group members are not authors, but may be listed in an acknowledgment.

Introduction: Population health involves integration of health, education, and social services to keep a defined population healthy, to address health challenges holistically, and to assist with the realities of being mortal. The fragmentation of the US population health delivery system is addressed. The impacts of this fragmentation on the treatment of substance abuse in the United States are considered. Innovations needed to overcome this fragmentation are proposed., Approach: Treatment capacity issues, including scheduling practices, are discussed. Costs of treatment and lack of treatment are considered. Models of integrated care delivery are reviewed. Potential innovations from systems science, behavioral economics, and social networks are considered. The implications of these innovations are discussed in terms of information technology (IT) systems and governance., Conclusions: Enormous savings are possible with more integrated treatment. Based on a range of empirical findings, it is argued that investments of these resources in integrated delivery of care have the potential to dramatically improve health outcomes, thereby significantly reducing the costs of population health., Competing Interests: The authors have no conflicts of interest.

Introduction: The overall enterprise of health care delivery is considered. The 4 levels of the enterprise include clinical practices, processes that provide capabilities and information, structure that includes the business entities involved, and ecosystem that includes Centers for Medicare and Medicaid Services and Congress, as well as societal values and norms. It is argued that the enterprise of health care delivery needs to be transformed to enable high-quality, affordable care for everyone., Discussion: The constructs of enterprise transformation and organizational learning are reviewed. The distinction of single-loop versus double-loop learning is discussed and illustrated for all levels of the health care delivery enterprise. Three health care examples are used to elaborate this distinction-cancer, population health, and health IT. Four strategies are outlined that the health care delivery enterprise can use to more effectively learn at all levels of the enterprise., Conclusions: This overall line of reasoning suggests several important research issues. The health care delivery enterprise involves much more than treating disease and paying for it. We need to improve our methods and tools for addressing the overall enterprise. Research is also needed on better means for portraying consequences of decisions to the full range of stakeholders in the enterprise. In general, the overall goal should be a healthy, educated, and productive population that is competitive in the global marketplace. We need to better understand the available levers for achieving this goal and how to best portray the intricacies of the overall enterprise to motivate those who can pull these levers to do so.

Significant reform of the health care system sufficient to achieve universal coverage, a value-driven system and administrative simplification faces enormous barriers at the level of our societal ecosystem - barriers as large as any that can be faced in public policy. These barriers exist within the health system itself as a complex adaptive system, and are structured by our economic, legal, cultural and political systems. Because there are so many barriers, significant reform is a relatively rare occurrence. Yet it does happen and there are some important examples of major health care reforms. There are a number of lessons to be learned from the successful enactment of the Medicare and Medicaid programs that appear relevant to current and future reform efforts. First, a necessary condition for achieving significant reform is the existence of large and sufficiently enduring social forces sufficient to disrupt legislative and policy stasis and drive the necessary political solutions. Second, public sentiment and electoral "mandates" might be necessary to significant reform, but they are not sufficient. Third, assuming the theoretical capacity to manage the constellation of systemic, economic, legal, cultural and legislative barriers, there remains a political "tipping point" that must be crossed and translated into a Congressional super-majority in order to enact significant nationwide reform.

Few would dispute that health care should be provided in seamless, well-integrated clinical care environments that bring together the various disciplines needed to provide patient-centered care, to educate trainees, and to conduct research into a particular disease or episode of care. Yet there are relatively few examples of successful or sustained clinical integration, either in the community setting or in academic health centers (AHCs). The authors draw on their experience with several AHCs and other health care settings to address why AHCs have not made better progress in developing integrated centers of clinical care. They characterize two fundamental types of integration that have evolved within the AHC setting: lateral and vertical. Lateral integration tends to occur among similarly situated specialties. It is easier to accomplish and far more common than is vertical integration, which brings together most, if not all, of the professionals and staff necessary to treat or manage many medical conditions and health problems. The vast majority of examples of clinical integration, whether lateral or vertical, fail to integrate essential administrative and financial functions, which has significant consequences for the ability of either laterally or vertically integrated centers to provide seamless, patient-centered care. The authors identify the emergence of several new examples of vertical clinical integration that also integrate administrative and financial functions as models for AHCs to follow and derive lessons and recommendations concerning how AHCs and others can address the cultural, financial, and governance issues that continue to limit the development of vertically integrated, patient-centered care.